Five Changes in DSM 5 Principles for Primary Care Tom Janzen, M.D. STEGH Mental Health May 14, 2014
Overall Learning Objectives Review 5 changes to DSM 5 which have significance for Family Physicians Examine the new definition of Mental Illness Identify tools for assessing impairment
DSM 5 Is it Really Different? Most of the things we see we already know the diagnostic criteria for them. Perry A. Pugno, MD, MPH, Vice President for education, American Academy of Family Physicians, June 17, 2013
DSM A brief history
Nosology of Mental Disorders 1840 Single Category Idiocy/Insanity 1880 Seven Categories 1917 - American Psychiatric Association Statistical Manual for use of Institutions for the Insane 1943 Medical 203 Post War Technical Bulletin (first non-institution) 1949 WHO ICD-6 First inclusion of Mental Illness One 7 22
The History of DSM 1952 First Edition of DSM Adaptation of Medical 203 1968 2 nd Edition DSM 1980 Robert Spitzer to chair DSM III taskforce 1974 Goal to improve uniformity of diagnosis (Rosenhan experiment) Establish criteria to aid pharmaceutical regulatory process Medical Insurance push to legitimize mental illness diagnosis 1987 DSM IIIR Multi-axial diagnosis Recognized PTSD in post war vets 106 182 265 292
The History of DSM 1994 DSM IV Clinical Significance Criterion Impairment in social, occupational or other areas 2000 2000 DSM IV TR (Allen Frances chair) Increased descriptions of disorders Move from consensus based to evidence based 365 365
Change #1 DSM 5 not V Intent
DSM 5 Intent Re-define the meaning of a mental illness Add dimensional criteria Age differences Gender differences Cultural differences Embrace evidence as it emerges Genetics and pharmacogenomics Structural and functional imaging Continued search for neurobiological markers American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing
DSM 5 Striving to be Etiologic Mental Illnesses are caused by complex interactions of multiple factors Different stressors can result in similar symptom clusters Similar stressors can result in very different clinical presentations DSM 5 strives to include the dimensional aspects of mental illness American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing
Change #2 Defining Mental Illness
WHO Definitions Health a state of complete physical, mental and social wellbeing and not merely the absence of infirmity Mental Health a feeling of well-being in which the individual realizes his/her own abilities, can cope with normal stresses of life, can work productively and fruitfully, and is able to make contributions to his or her community
Defining Mental Illness A mental disorder is a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering, death, pain, disability, or an important loss of freedom. DSM IV (1992-2013)
DSM 5 Definition "A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. DSM 5 (May 16, 2013)
DSM 5 A Mental Illness IS NOT An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual
Change #3 Impairment
Sheehan Disability Scale
GAF to WHODAS
Change #4 Anxiety and Related Disorders
Chapter 5: Anxiety Disorders DSM IV-TR Panic Disorder with or without Agoraphobia Agoraphobia without Panic Disorder Social Phobia [Social Anxiety Disorder] Specific Phobia Generalized Anxiety Disorder Obsessive Compulsive Disorder Post Traumatic Stress Disorder Anxiety NOS Panic Disorder Agoraphobia DSM 5 Social Anxiety Disorder [Social Phobia] Specific Phobia Generalized Anxiety Disorder Separation Anxiety Disorder Selective Mutism Moved from Anxiety Disorders in DSM IV Removed from DSM 5 Added to DSM 5
CHAPTER 6: OBSESSIVE-COMPULSIVE AND RELATED DISORDERS Obsessive Compulsive Disorder (OCD) Body Dysmorphic Disorder (BDD) Trichotillomania (Hair-Pulling Disorder) Excoriation (Skin Picking) Disorder Hoarding Disorder Moved from Impulse Control Disorder Added to DSM 5
CHAPTER 7: TRAUMA/STRESSOR RELATED DISORDERS ANXIETY Disorders Preceded by Distressing or Traumatic Event Posttraumatic Stress Disorder (PTSD) Acute Stress Disorder Adjustment Disorders Reactive Attachment Disorder Disinhibited Social Engagement Disorder Moved from its own chapter Added to DSM 5
ADJUSTMENT DISORDERS Same Criteria as DSM IV-TR Subtypes (DSM IV-TR) Specifiers (DSM 5) ** With Depressed Mood With Anxiety With Disturbed Conduct With Mixed Anxiety and Depressed Mood With Mixed Disturbance of Emotions *The symptoms do not represent normal bereavement ** Specifiers replace DSM IV-TR Subtypes
Change #5 SIGECAPS Survives the Change
Acronym for DSM 5 Criteria: MDD SIGECAPS
Measurement Based Care Sig: E Caps and PHQ-9 S I G Core Symptoms of Depression Depressed Mood Sleep decreased Interest decreased in activities (anhedonia) Guilt or worthlessness E C A P S Energy decreased Concentration difficulties Appetite disturbance or weight loss Psychomotor retardation / agitation Suicidal thoughts SIGECAPS PHQ-9 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 2000:352. Ohayon MM, et al. J Clin Psychiatry 2004;65[suppl 12]:5 9 BCMJ, Vol. 44, No. 8, October 2002, page(s) 415-419
THE ANXIETY SPECIFIER IN MDD Specifier With Anxious Distress Assess if symptoms present: 1. Keyed up/tense 2. Unusually restless 3. Difficulty concentrating because of worry 4. Fear that something awful may happen 5. Feeling of losing control of self Assess Severity: Mild - 2 symptoms Moderate - 3 symptoms Moderate to Severe - 4 symptoms Severe - 4 to 5 symptoms with motor agitation Diagnosis: MDD with Anxious Distress (Moderate)
Summary DSM 5 intends to better capture the individual experience Perhaps it s biggest achievement is to acknowledge what we don t know